Provider Demographics
NPI:1285663591
Name:SMITH, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-2841
Mailing Address - Country:US
Mailing Address - Phone:601-948-5572
Mailing Address - Fax:601-353-7070
Practice Address - Street 1:1134 WINTER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-2841
Practice Address - Country:US
Practice Address - Phone:601-948-5572
Practice Address - Fax:601-353-7070
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00011675Medicaid
MS251850Medicare Oscar/Certification
MSCC2133Medicare Oscar/Certification
MS080001897Medicare PIN
MS080056992Medicare PIN
MS251933Medicare Oscar/Certification
MSC48122Medicare UPIN
MS00011675Medicaid
MS251936Medicare Oscar/Certification